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Shah HR, Hiremath A, Munshi P, Thatte MR. A Tardy Ulnar Palsy with an Anomalous Course of Ulnar Nerve. Indian J Plast Surg 2023; 56:280-282. [PMID: 37435348 PMCID: PMC10332889 DOI: 10.1055/s-0043-1768915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2023] Open
Abstract
Variations are inherent feature of the intricate brachial plexus. They can be at the level of origin, the course, or the innervation pattern of each peripheral nerve. Knowledge of the various described variations can be worthwhile during the routine hand surgery procedures. We present a case of an elderly patient with anomalous intramuscular course of the ulnar nerve presenting with ulnar neuropathy at the elbow. Level of Evidence: IV.
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Affiliation(s)
- Harsh R. Shah
- Department of Plastic and Reconstructive Surgery, Bombay Hospital and Institute of Medical Sciences, Mumbai, Maharashtra, India
| | - Amita Hiremath
- Department of Plastic Surgery, Bombay Hospital and Institute of Medical Sciences, Mumbai, Maharashtra, India
| | - Parag Munshi
- Department of Orthopedics, Bombay Hospital and Institute of Medical Sciences, Mumbai, Maharashtra, India
| | - Mukund R. Thatte
- Department of Plastic Surgery, Bombay Hospital and Institute of Medical Sciences, Mumbai, Maharashtra, India
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Lasso JM, Ibarra G, Rivera A, Fernandez-Ibarburu B, Olivares M, de la Cruz I, Gomez-Navarro Y, Garcia M. Anatomic and histomorphometric study of the nerve to the vastus lateralis in cadaver for its clinical application in facial reanimation. Microsurgery 2023; 43:365-372. [PMID: 36645336 DOI: 10.1002/micr.31005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 11/18/2022] [Accepted: 12/30/2022] [Indexed: 01/17/2023]
Abstract
BACKGROUND The innervated vastus lateralis flap (IVLF) is a barely used possibility for facial palsy reconstruction because of its thickness compared to the gracilis, latissimus dorsi, and pectoralis minor flaps. The aim of this study is to perform a precise description of the intramuscular distribution of the nerve motor branches and its relationship with the vascular pedicle in order to harvest a segmental muscle flap with the best contractile strength to restore facial reanimation. METHODS The study was performed on 16 adult cadaver thighs identifying the vastus lateralis muscle and the distribution and relationships of its neurovascular pedicle and branches. We evaluated where the nerve pierced the muscle and the course of the nerve within it. Transverse segments of the nerve were obtained from the proximal and distal ends of the nerve and stained using anti-ChAT (Choline acetyltransferase) antibodies which are specific of motor neurons. RESULTS A nerve for the vastus lateralis from the posterior division of the femoral nerve divided into 2 branches in 56% of cases; the principal branch coursed along the vascular pedicle and pierced the muscle more proximally than the respective vessels, and a minor branch that pierced the muscle 25-60 mm proximally. There were 3 main intramuscular branches. The nerve length (mean 132.65 ± 22.89 mm) allowed to reach the contralateral side of the face in almost all cases (95%). The mean ChAT positive fibers was 351.0 ± 92.4/mm2 at the proximal end, and 270.3 ± 87.9/mm2 at the distal end (p = 0.49). The number of ChAT negative fibers was higher than ChAT positive in both proximal and distal ends of the nerve. CONCLUSION We propose the IVLF as a one-step surgical flap for facial paralysis reanimation due to the constant neurovascular pattern and lengthy pedicle. The amount of motor fibers in several segments of the nerve is appropriate to produce a powerful contraction for dynamic reconstruction.
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Affiliation(s)
- Jose M Lasso
- Plastic and Reconstructive Surgery Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Gorka Ibarra
- Plastic and Reconstructive Surgery Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Andres Rivera
- Plastic and Reconstructive Surgery Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Borja Fernandez-Ibarburu
- Plastic and Reconstructive Surgery Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Martin Olivares
- Plastic and Reconstructive Surgery Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Ignacio de la Cruz
- Plastic and Reconstructive Surgery Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Yesica Gomez-Navarro
- Pathology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain
| | - Maria Garcia
- Pathology Department, Hospital General Universitario Gregorio Marañon, Madrid, Spain
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Bertelli JA, Goklani MS, Patel N, Duarte ECW. Triceps and cutaneous radial nerve branches investigated via an axillary anterior arm approach: new findings in a fresh-cadaver anatomical study. J Neurosurg 2022; 136:1424-1433. [PMID: 34624848 DOI: 10.3171/2021.4.jns2169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 04/06/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors sought to describe the anatomy of the radial nerve and its branches when exposed through an axillary anterior arm approach. METHODS Bilateral upper limbs of 10 fresh cadavers were dissected after dyed latex was injected into the axillary artery. RESULTS Via the anterior arm approach, all triceps muscle heads could be dissected and individualized. The radial nerve overlaid the latissimus dorsi tendon, bounded by the axillar artery on its superior surface, then passed around the humerus, together with the lower lateral arm and posterior antebrachial cutaneous nerve, between the lateral and medial heads of the triceps. No triceps motor branch accompanied the radial nerve's trajectory. Over the latissimus dorsi tendon, an antero-inferior bundle, containing all radial nerve branches to the triceps, was consistently observed. In the majority of the dissections, a single branch to the long head and dual innervations for the lateral and medial heads were observed. The triceps long and proximal lateral head branches entered the triceps muscle close to the latissimus dorsi tendon. The second branch to the lateral head stemmed from the triceps lower head motor branch. The triceps medial head was innervated by the upper medial head motor branch, which followed the ulnar nerve to enter the medial head on its anterior surface. The distal branch to the triceps medial head also originated near the distal border of the latissimus dorsi tendon. After a short trajectory, a branch went out that penetrated the medial head on its posterior surface. The triceps lower medial head motor branch ended in the anconeus muscle, after traveling inside the triceps medial head. The lower lateral arm and posterior antebrachial cutaneous nerve followed the radial nerve within the torsion canal. The lower lateral brachial cutaneous nerve innervated the skin over the biceps, while the posterior antebrachial cutaneous nerve innervated the skin over the lateral epicondyle and posterior surface of the forearm. The average numbers of myelinated fibers were 926 in the long and 439 in the upper lateral head and 658 in the upper and 1137 in the lower medial head motor branches. CONCLUSIONS The new understanding of radial nerve anatomy delineated in this study should aid surgeons during reconstructive surgery to treat upper-limb paralysis.
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Affiliation(s)
- Jayme A Bertelli
- 1Department of Orthopedic Surgery, Governador Celso Ramos Hospital, Florianópolis, Santa Catarina, Brazil
| | - Mayur Sureshlal Goklani
- 2Department of Plastic Surgery, Bombay Hospital Institute of Medical Sciences, New Marine Lines, Mumbai, Maharashtra, India
| | - Neehar Patel
- 3Department of Plastic Surgery, Wockhardt Hospital, The Umrao IMSR, Mumbai, Maharashtra, India; and
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Singh S, Das KK, Deora H, Jaiswal AK, Behari S. Traumatic Partial Posterior Cord Brachial Plexus Injury in a Patient with Aberrant Innervation of the Long Head of the Triceps by the Axillary Nerve: Implications in Nerve Transfer Surgery. Asian J Neurosurg 2020; 15:391-393. [PMID: 32656138 PMCID: PMC7335135 DOI: 10.4103/ajns.ajns_160_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Accepted: 01/21/2020] [Indexed: 11/10/2022] Open
Abstract
Brachial plexus repair forms an unmet need in terms of posttraumatic rehabilitation, especially the young population, wherein the incidence of accidents is high. This leads to decrease in the number of functionally active years after the accident. We encountered an interesting case of posttraumatic posterior cord injury predominantly affecting the shoulder abduction beyond 15°. An electrodiagnostic study showed a complete lack of conduction within the axillary nerve with reduced conduction velocity in the radial nerve. We took the patient up for the long head of the triceps transfer to the anterior division of the axillary nerve transfer. Intraoperatively, we found that the long head branch was originating from the axillary nerve at the point of division. As it could not be used for neurotization, we transferred the medial head branch of the radial nerve to the axillary nerve. The patient started to show electroclinical improvement after 3 months of the surgery. A few similar cases have been published, as a cadaveric finding. We report this case to highlight the possibility and need for a high clinical suspicion and also to provide a possible treatment option, in such aberrant anatomy.
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Affiliation(s)
- Suyash Singh
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Kuntal Kanti Das
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Harsh Deora
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Awadhesh Kumar Jaiswal
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Sanjay Behari
- Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Lasso JM, Maranillo E, Martinez-Pascual P, Goñi E, Vazquez T, Sanudo J, Pascual-Font A. Anatomical study of the masseteric and obturator nerves: Application to face transplant and reanimation procedures. Clin Anat 2019; 32:612-617. [PMID: 30786070 DOI: 10.1002/ca.23357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 01/17/2019] [Accepted: 02/18/2019] [Indexed: 11/11/2022]
Abstract
The masseteric nerve (MN) and the anterior branch of the obturator nerve (ON) that innervate the transferred gracilis muscle have proved highly efficient for reanimating paralyzed facial muscles when muscle transfer is required. Previous researchers have published the total axonal load for myelinated fibers in both nerves. However, the real motor axonal load has not been established. We performed the study on 20 MN and 13 ON. The segments of the MN and the ON were embedded in paraffin, sectioned at 10 μm, and stained following a standard immunohistochemical procedure using anti-choline acetyltransferase to visualize the motor fibers. The MN has a higher axonal load than the ON. There were statistically significant differences between the axonal load of the proximal segment of the MN and the ON. These findings confirm that end-to-end anastomoses between the MN and the ON should preferably use the proximal segment. However, MN neurotomy should ideally be performed between the proximal and distal segments, preserving innervation to the deep fascicles. Our results show that the MN is ideal as a donor motor nerve for reinnervating transplanted muscle for dynamic reanimation of the paralyzed face. The neurotomy should ideally be performed between the first and second collateral branches of the MN. Clin. Anat. 32:612-617, 2019. © 2019 Wiley Periodicals, Inc.
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Affiliation(s)
- Jose M Lasso
- Department of Plastic Surgery, Hospital Gregorio Marañón, Madrid, Spain
| | - Eva Maranillo
- Department of Anatomy and Embryology, School of Medicine, Complutense University of Madrid, Madrid, Spain
| | | | - Ender Goñi
- Department of Plastic Surgery, Hospital Gregorio Marañón, Madrid, Spain
| | - Teresa Vazquez
- Department of Anatomy and Embryology, School of Medicine, Complutense University of Madrid, Madrid, Spain
| | - Jose Sanudo
- Department of Anatomy and Embryology, School of Medicine, Complutense University of Madrid, Madrid, Spain
| | - Aran Pascual-Font
- Department of Anatomy and Embryology, School of Medicine, Complutense University of Madrid, Madrid, Spain
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Jain DKA, Kumar ST, Shetty N. Ulnar Nerve Innervation to Triceps: A Cadaveric Study and a Technical Note on Partial Triceps to Biceps Transfer. Indian J Orthop 2019; 53:353-356. [PMID: 30967708 PMCID: PMC6415570 DOI: 10.4103/ortho.ijortho_440_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The loss of elbow flexion is a routinely encountered problem in clinical practice. There is no literature on ulnar nerve innervation to triceps in addition to the radial nerve which is dual nerve innervation to triceps in the Indian population. We intend to study the incidence of ulnar nerve innervation to the medial head of triceps in Indian population and also the clinical feasibility of transfer of long and medial head of triceps tendon to biceps around the medial aspect of humerus. MATERIALS AND METHODS A cross-sectional study was conducted using 32 fresh-frozen skeletally mature cadavers of Indian origin. The possible contribution of the ulnar nerve to medial head of triceps in addition to the radial nerve was recorded. The arm length, the distance where the ulnar nerve pierces the medial intermuscular septum from medial epicondyle; the distance of the ulnar nerve fascicle from the medial epicondyle was also measured. RESULTS The incidence of ulnar nerve innervation to the medial head of triceps was 43.8%. Mean arm length was 29.13 cm. Mean distance where the ulnar nerve pierced the medial intermuscular septum from medial epicondyle was 9.93 cm. Mean distance of the ulnar nerve branch to the triceps from medial epicondyle was 8.01 cm. CONCLUSION This study reveals the presence of dual nerve innervation to triceps in 43.8% of the Indian population. The clinical implication would be to look for the possible contribution of the ulnar nerve fascicle to the medial head of triceps, which will help us to include the medial head along with the long head of triceps while performing partial triceps-to-biceps tendon transfer, and the other use would be as a donor fascicle when performing a nerve transfer.
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Affiliation(s)
- Darshan Kumar A Jain
- Department of Orthopaedics, Ramaiah Medical College, Bengaluru, Karnataka, India,Address for correspondence: Dr. Darshan Kumar A Jain, Department of Orthopaedics, Ramaiah Medical College, Bengaluru, Karnataka, India. E-mail:
| | - Sathish T Kumar
- Department of Orthopaedics, Ramaiah Medical College, Bengaluru, Karnataka, India
| | - Naresh Shetty
- Department of Orthopaedics, Ramaiah Medical College, Bengaluru, Karnataka, India
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Cho SH, Chung IH, Lee UY. Relationship between the ulnar nerve and the branches of the radial nerve to the medial head of the triceps brachii muscle. Clin Anat 2018; 32:137-142. [PMID: 29770497 DOI: 10.1002/ca.23207] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 03/14/2018] [Accepted: 05/08/2018] [Indexed: 11/06/2022]
Abstract
One branch of the radial nerve to the medial head of the triceps brachii muscle (MHN) has been described as accompanying or joining the ulnar nerve. Mostly two MHN branches have been reported, with some reports of one; however, the topographical anatomy is not well documented. We dissected 52 upper limbs from adult cadavers and found one, two, and three MHN branches in 9.6%, 80.8%, and 9.6% of cases, respectively. The MHN accompanying the ulnar nerve was always the superior MHN. The relationship between the ulnar nerve and the MHN was classified into four types according to whether the MHN was enveloped along with the ulnar nerve in the connective tissue sheath and whether it was in contact with the ulnar nerve. It contacted the ulnar nerve in 75.0% of cases and accompanied it over a mean distance of 73.6 mm (range 36-116 mm). In all cases in which the connective tissue sheath enveloped the branch of the MHN and the ulnar nerve, removing the sheath confirmed that the MHN branch originated from the radial nerve. The detailed findings and anatomical measurements of the MHN in this study will help in identifying its branches during surgical procedures. Clin. Anat. 00:1-16, 2018. © 2018 Wiley Periodicals, Inc.
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Affiliation(s)
- Sung Hun Cho
- Catholic Institute for Applied Anatomy, Department of Anatomy, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - In-Hyuk Chung
- Catholic Institute for Applied Anatomy, Department of Anatomy, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - U-Young Lee
- Catholic Institute for Applied Anatomy, Department of Anatomy, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
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Chaware PN, Santoshi JA, Patel M, Ahmad M, Rathinam BAD. Surgical Implications of Innervation Pattern of the Triceps Muscle: A Cadaveric Study. J Hand Microsurg 2018; 10:139-142. [PMID: 30483020 DOI: 10.1055/s-0038-1660771] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 05/01/2018] [Indexed: 10/28/2022] Open
Abstract
The innervation pattern of triceps is complex and not fully comprehended. Anomalous innervations of triceps have been described by various authors. We have attempted to delineate the nerve supply of the triceps and documented the anomalous innervations of its different heads. The brachial plexus and its major branches (in the region of the axilla and arm) and triceps were dissected in 36 embalmed cadaver upper limbs. Long head received one branch from radial nerve in 31 (86%) specimens. Four (11%) specimens received two branches including one that had dual innervation from the radial and axillary nerves, and one (3%) specimen had exclusive innervation from a branch of the axillary nerve. Medial head received two branches arising from the radial nerve in 34 (94%) specimens. One (3%) specimen received three branches from the radial nerve whereas one (3%) had dual supply from the radial and ulnar nerves. Lateral head received multiple branches exclusively from the radial nerve, ranging from 2 to 5, in all (100%) specimens. Knowledge of the variations in innervation of the triceps would not only help the surgeon to avoid inadvertent injury to any of the nerve branches but also offers new options for nerve and free functional muscle transfers.
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Affiliation(s)
| | - John Ashutosh Santoshi
- Department of Orthopaedics, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Manmohan Patel
- Department of Anatomy, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Mohtashim Ahmad
- Department of Anatomy, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| | - Bertha A D Rathinam
- Department of Anatomy, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
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Connections between radial and ulnar nerve at high humeral level in cadavers: incidence, topography, and literature review. Surg Radiol Anat 2017; 40:313-322. [PMID: 29124342 DOI: 10.1007/s00276-017-1939-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2017] [Accepted: 10/27/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE Although communications between branches and cords of the brachial plexus have been extensively published, there is a scarcity of reports concerning radial and ulnar nerve (RN-UN) communication in the arm. The current study aims to demonstrate the incidence, topography, and length of communicating branches between RN and UN. Any additional coexisted variations were also recorded. MATERIALS AND METHODS Two hundred and sixty-six upper limbs collected from one hundred and thirty-three (81 males and 52 females) Greek cadavers were dissected. RESULTS Three out of one hundred and thirty-three cadavers, accounting for an incidence of up to 2.3%, were found to have an atypical communicating branch originating at a high humeral level from RN towards UN. In two cadavers, communicating branches were detected on the left side and in one cadaver bilaterally. CONCLUSIONS The study of atypical communications between RN and UN attracts great attention for its clinical importance, mainly in cases of peripheral neuropathies with diagnostic dilemma or upper limb nerve injury producing an otherwise unexpected symptomatology due to the aberrant nerve supply. Familiarity with these variations is crucial in avoiding misdiagnosis and preserving valuable communicating branches, thus achieving an uneventful outcome in cases of upper limb nerve injury repair.
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